Opioid-Prescribing Patterns in Connecticut and New Jersey Following Third Molar Extractions

On October 26, 2017, the US Secretary of Health and Human Services declared the opioid crisis a national public health emergency.¹ The misuse and abuse of opioids in recent years has put much scrutiny on the prescribing habits of all health care providers. Millions of surgical procedures are done every year, and statistics suggest that patients' exposure to prescription opioids following surgery may ultimately lead to long-term use or abuse. In fact, 1 in 16 surgical patients becomes a long-term opioid user once prescribed opioids, demonstrating that providers may be contributing unwittingly to this epidemic in some capacity.² Data from the US National Survey on Drug Use and Health in 2013 indicated that as many as 4.5 million people 12 years and older reported using opioid-containing analgesics inappropriately, including taking more than prescribed, in combination with other substances, or for other reasons such as anxiety reduction, to improve sleep, and others.³

The 2019 data from the Substance Abuse and Mental Health Services Administration states, “among people aged 12 or older, the number of past year initiates of prescription pain reliever misuse declined from 2.1 million people in 2015 to 1.6 million people in 2019.”⁴ Despite the decrease, the opioid epidemic remains a substantial issue. These data also raise the question of whether prescribing habits have changed over time. To explore this question within the context of oral and maxillofacial surgery, the authors examined 1 region of the country. Connecticut and New Jersey had similar mortality rates due to opioid overdose in 2017 at 20.7 and 21.7 per 100,000, respectively,⁵ making them consistent areas to survey and compare.

The US consumes most of the opioids produced worldwide despite representing a fraction of the world's total population. Dentists have been identified as the second highest prescribers of immediate-release opioids in the United States, accounting for 12% of all prescriptions dispensed.^3,6,7 While many dental procedures can cause some pain, surgical extractions are considered one of the most painful. Third molar extractions are a well-established model for assessing postoperative pain. Approximately 10 million third molars are extracted from 5 million patients every year in the United States.⁸ Most people experience extraction of at least 1 third molar in their life, making this relatively common procedure useful for exploring postsurgical pain and accompanying prescribing habits.^9,10 Dental pain can be debilitating for patients, and it is essential for dental providers to effectively manage pain especially following invasive dental procedures. Nonsteroidal anti-inflammatory drug (NSAIDs) or acetaminophen (APAP) are often adequate to manage postoperative pain, but oftentimes providers prescribe opioids to help with the breakthrough pain when NSAIDs and APAP are not sufficient. The challenge becomes the minimizing risk of abuse and adequately addressing postoperative pain.

The primary outcome of this study was to analyze typical analgesic protocols and the most common analgesics prescribed by oral and maxillofacial surgeons (OMS) in Connecticut and New Jersey following third molar extractions. The goal of the study was to use this information as a model for promoting improved postsurgical pain management and fabricating best practice recommendations. The secondary goal was to explore alternatives for postoperative analgesia and prescribing practices.

METHODS

This cross-sectional study was conducted with the approval and compliance of the Columbia University Irving Medical Center's Institutional Review Board (protocol No. AAAT0381) and used an electronic survey sent to OMS practicing in Connecticut and New Jersey. Items of the survey included practice location, prescribing habits, specific analgesics used, and prescribing methods. Qualtrics Research Services (www.qualtrics.com), an online survey program, was used to recruit study participants and publish the final survey. Inclusion criteria were active members of the New Jersey Society of Oral and Maxillofacial Surgeons and the Connecticut Society of Oral and Maxillofacial Surgeons. Emails were sent out on May 5, 2020, a reminder email was sent 1 week later, and potential study participants had 2 weeks to complete the survey.

Descriptive statistical analyses and t tests were performed where appropriate using SAS Studio (SAS 9.4M6, 2018, SAS Institute) to quantify the number of opioids prescribed and to determine if the quantity changed based on other factors, such as intraoperative use of ketorolac, steroids, or long-acting local anesthetics (eg, bupivacaine). Statistical significance was defined as a P < .05.

RESULTS

Overall, 291 practitioners were contacted via email, and 84 complete responses (29%) were recorded. Of the total respondents, 57 OMS practiced in New Jersey, and 27 OMS practiced in Connecticut. There was no crossover of respondents who practice in both states.

Prescribing

Of the prescribing patterns presented in the survey (question 7), 30 of 84 respondents (36%) typically used 2 separate prescriptions: an NSAID and an opioid/APAP combination tablet. For the prescribing pattern question, respondents were allowed to choose only 1 answer, but all options and combinations were provided (survey available online as Appendix 1). Respondents, who then had the option to choose multiple medications from a list of common dosages, identified ibuprofen 600 mg, hydrocodone/APAP 5/325 mg, oxycodone/APAP 5/325 mg, and ibuprofen 800 mg as the most prescribed (Table 1). Most participants (83%) reported prescribing analgesics the same day the procedure was performed. Surprisingly, only 32% of participants had transitioned into prescribing electronically. An average of 10.93 ± 4.51 opioid pills were prescribed by providers, with a maximum of 20 pills reported.

Table 1. Summary of Respondent Prescribing Trends and Postoperative Analgesic Agents*

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Prescribing Practices

A large majority of those surveyed (88%) reported that the number of opioids they prescribe had decreased in the past 2 years. Just less than half (48%) of respondents said that they always, and an additional 31% frequently, provide information on the safe use, storage, and disposal of opioids to patients/parents (Table 2). Only 22% reported always referring to their state's prescription-monitoring program, whereas 47% stated they occasionally reference it. There was an association found between the number of opioid pills prescribed and how often the provider checked the state's prescription-monitoring program. Providers were more likely to always or frequently check the prescription-monitoring program if prescribing more than the mean number of opioid pills (>10.93; P = .0228; Table 3).

Table 2. Respondents' Prescribing and Providing Opioid Information Habits*

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Table 3. Respondent's Utilization of Opioid-Monitoring Programs*

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Pain Management Alternatives

While more than half (56%) of the practitioners surveyed reported using intraoperative long-acting local anesthetics routinely during third molar extractions, there was no association found with prescribing lower quantities of opioids (P = .067). Similarly, there was no association between those who administer intravenous (IV) ketorolac or dexamethasone intraoperatively or a Medrol Dose Pak postoperatively and the quantity of opioids prescribed (P > .05; Table 4). Bupivacaine was identified as the long-acting anesthetic of choice (70%) of those surveyed. Use of liposomal bupivacaine for extended release was reported by 7% of respondents (Figure).

Table 4. Use of Pain Management Alternatives and Correlation With Reduced Opioid Prescriptions*

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DISCUSSION

The typical third molar patient presents as a young, healthy adult with no underlying medical conditions, which makes third molar extractions a predictable surgery for comparison.^8–10 Opioids can provide effective pain management following third molar extractions, and dental surgeons who prescribe these pain medications often instruct patients to take them “as needed.”¹¹ This type of instruction removes control from the provider and puts it in the hands of the patient to determine when pain medication is “needed.” While many OMS prescribe opioids, our study found that less than half always provide patients with information regarding opioids, demonstrating room for improvement. Disseminating information about opioids is vital in educating patients about the dangers and long-term consequences that can come with opioid use and should always accompany every opioid prescription.

In a study published in the Journal of the American Dental Association in 2019, codeine with APAP was the primary opioid prescribed (97.4%) among dentists in Manitoba, Canada, in a longitudinal analysis.⁶ In our survey, hydrocodone/APAP combinations were the most commonly used opioids, prescribed by 58% (49/84) of respondents. This was followed by oxycodone/APAP, which was prescribed by 37% (31/84) of respondents. It remains unclear whether this difference reflects regional differences between US and Canadian providers or a recent change in prescribing preferences.

Of those surveyed, only 30% stated they prescribed only ibuprofen or ibuprofen/APAP to their patients who underwent third molar extractions. Only 8% reported prescribing ibuprofen, APAP, and an opioid as 3 separate prescriptions. This is significant, as it has been well-documented that alternating between ibuprofen and APAP on a regular schedule is superior to taking opioids alone after the patient begins experiencing pain.¹² While prescribing an opioid combined with APAP is simpler for patients, it can increase patient confusion when their postoperative analgesic regimen also includes other APAP formulations (for example, instructing patients to stop APAP if converting over to an opioid/APAP combination due to breakthrough pain). For this reason, it is the authors' recommendation, based on the practices of Columbia University Medical Center, to have patients take ibuprofen and APAP every 6 hours, alternating between the two every 3 hours. This simple approach amounts to 1 pill every 3 hours, assuming prescription ibuprofen and APAP is used. A noncombination opioid pill should also be prescribed, reserved for breakthrough pain only. While this may decrease patient compliance, consistent control of the patient's pain should decrease the need for opioid use and permit smaller opioid prescriptions. This approach is currently practiced at Columbia University Medical Center, and most patients seem to understand the need to take the NSAID/APAP as scheduled every few hours to minimize swelling and appreciate that the third prescription is only for intolerable breakthrough pain. We also provide written instructions with examples for when to take the prescriptions (e.g., 12:00 pm APAP, 3:00 pm ibuprofen, 6:00 pm APAP, etc). Some argue that there is no clinical difference between alternating ibuprofen/APAP every 3 hours or taking both together every 6 hours for even greater simplicity. The logic behind our recommendations is that the peak blood concentrations are staggered and thus should provide a more consistent level of pain control. However, this is difficult to study and has been proven only anecdotally. Thus, it is up to the individual practitioner to advise patients on the timing of ibuprofen and APAP use, but the authors are suggesting the protocol used at our institution.

When opioid pain medications are indicated, it is important to educate patients as to how to get ahead of the pain through nonopioid medications such as APAP and NSAIDs whenever possible. In our survey, the average quantity of opioids prescribed was 10.93 pills. Writing an opioid prescription separately allows for a reduction in the quantity of opioid pills. In our study, we found that only 8% of OMS currently write 3 separate prescriptions for an opioid, NSAID, and APAP. By writing 3 separate prescriptions, providers can prescribe fewer opioids and encourage the patient to use the NSAID and APAP to manage baseline pain following third molar extraction. This also separates the association of opioids with APAP in the patient's mind and can aid in avoiding unnecessary opioid consumption. The NSAIDs and APAP can reduce most postoperative pain, allowing the patient to potentially need only 1 or 2 opioid tablets for breakthrough pain. When using combination pills, patients tend to rely on the opioid to provide baseline pain control. Explaining the level of pain to patients and managing patient expectations can be beneficial in limiting the amount of opioid medication needed.

US federal and state governments have tried to address the opioid crisis in many ways. In 2017, the US Department of Health and Human Services introduced the “5-Point Strategy to Combat the Opioid Crisis” initiative. Part of this initiative included issuing more than $800M in grants to help combat this crisis.¹³ These grants went to organizations and programs throughout the United States focused on developing new treatment drugs, support and recovery systems, first responder training, and opioid research. Many states have instituted prescription-monitoring programs. Requirements for the monitoring programs vary by state, but most states, including Connecticut and New Jersey, suggest or require the practitioner to check the system before prescribing more than a 72-hour supply of opioids. Our study found that OMS are not consulting their state's prescription-monitoring program every time they write an opioid prescription, as only 22% reported always checking. Ten percent reported never referring to it, and 47% stated they occasionally reference the program prior to prescribing opioids. While legally it is not required, ideally the databases should be reviewed prior to any opioid prescription. Fortunately, those who provide a higher quantity of opioids than this study's average of ∼11 opioid pills were found to be more likely to reference the prescription-monitoring program.

Encouraging practitioners to provide information regarding the safe use, storage, and disposal of opioids to every patient and family is essential for combating the opioid crisis. Most of the respondents consistently provided this information to patients; however, a portion (22%) did not. This reflects yet another area for improvement. In addition, many state medical boards require mandatory continuing education in opioid prescribing before license renewals. Patients also have access to the Substance Abuse and Mental Health Services Administration hotline. This hotline is available 24/7 and provides a free, confidential service for anyone looking for information about substance abuse disorders.

Other ways of decreasing opioid prescribing can include the use of alternative pain control methods. Ketorolac is an extremely efficacious analgesic, but only 15% of those surveyed use it in the office. Using a long-acting local anesthetic, such as bupivacaine, is another effective method for minimizing the need for postoperative opioids. A study conducted by Neal et al. found that patients administered regular bupivacaine were anesthetized 3.5 hours longer than those patients who received lidocaine.¹⁴ Liposomal bupivacaine (Experal, Pacira Pharmaceuticals, Inc.), which releases bupivacaine slowly over 72 hours, is another alternative for reducing postoperative opioids. Although our data show that it is not commonly used, it could potentially be offered to patients. These alternatives represent additional ways to further reduce the need for postoperative opioids and should be considered when appropriate.

Because of the nature of using a survey for data collection, there are intrinsic limitations present, including response bias, unclear understanding and interpretation of the questions being asked, and the possibility of a low response rate. Another limitation that our study had was that it was difficult to stratify some confounding variables based on those surveyed. Examples of confounding variables for which we were unable to account included when the surgeon trained as well as the location and philosophy of their respective training program. For future studies, we would like to develop an American Dental Association–sponsored national survey capable of reaching a broader audience and creating a more meaningful study with external validity.

CONCLUSION

Through this study, we have shown that there are various methods for managing pain following third molar extractions, including many beyond simply prescribing opioids. The most common approach included an NSAID plus an opioid/APAP combination written as 2 separate prescriptions. The combination of hydrocodone/APAP was the most prescribed opioid analgesic. Most OMS respondents reported that they consistently provide opioid information to patients, although most failed to consistently check monitoring programs prior to writing an opioid prescription. Of the OMS surveyed in this study, 88% indicated that their opioid prescribing habits have decreased over the past 2 years. While many of these trends are encouraging, there is still more work to be done. Continued self-reflection on our individual prescribing habits and assessment of our practice habits to determine ways to further improve acute pain management while minimizing opioid risks are clearly recommended.